On October 13, ASA President-Elect Jeffrey Plagenhoef, M.D., spoke at the Brookings Institution forum, Protecting Patients from Surprise Medical Bills. The think tank briefing was timed with the release of a Brooking policy paper on this topic and featured two panels: stakeholder and policymaker perspectives.
During the stakeholder panel, Dr. Plagenhoef explained that balance billing is a symptom of a much larger problem and pointed to “gaps in insurance coverage” as the root cause. Much like with the treatment of disease, he explained, it is insufficient to merely treat the symptoms. Instead, a comprehensive approach that includes “accessible networks with an adequate number of all providers and all services, as well as a mechanism for fair out-of-network payment” is key to solving this multi-faceted issue.
ASA has shown strong leadership and is a leading voice on Out-of-Network payment issues. To that end, Dr. Plagenhoef has worked tirelessly with ASA’s Ad Hoc Committee on Out-of-Network Payment to educate physician leaders on this emerging advocacy issue and cautions that “if we do not aggressively respond to this threat, access to care and the future of physician anesthesiologists’ groups, departments and practices are very much at risk!"
Dr. Plagenhoef’s Brooking’s comments highlighted the failure of insurance companies to maintain adequate and readily accessible networks. He also shared that there are increasing reports of insurance companies narrowing networks to limit their costs and shift those costs to patients and other stakeholders. Tiering, where a physician can be in-network with a carrier in one tier and out of network with the same carrier in a different tier, is an additional problem. Tiering further underscored the need for lawmakers considering pre-treatment/procedure cost estimate legislation to put the onus on insurance companies as they are the only ones who know whether a treating physician for a particular patient is in or out of that patient’s network at any given time.
To underscore the complexity of modern health insurance products, Dr. Plagenhoef shared his family’s personal experience with the subject. After extensive research prior to purchasing health insurance and before a procedure, his family received a bill 12 times what they had been told to expect.
Dr. Plagenhoef participated on the stakeholder panel, Addressing the Growing Problem of Surprise Medical Bills: Stakeholder Perspectives. In addition to Dr. Plagenhoef, other panelists included representatives from Consumers Union, Cedars-Sinai Medical Center, and Anthem, Inc. The second panel, Addressing the Growing Problem of Surprise Medical Bills: Policymaker and Policy Thinker Perspectives, included a representative from the Council of Economic Advisers, and professors of economics or political science from the University of Southern California, Yale University, and Georgetown University.
In the past several years, there has been a dramatic increase in media attention concerning bills patients receive from health care professionals who are not in the network of providers their insurance company contracted with to provide health services. The out-of-network bills these patients receive have been termed “surprise bills” by the insurance industry, but are also often termed “balance billing” or “out-of-network billing.” Balance billing occurs when a patient receives a bill for the amount remaining between the out-of-network provider’s charge and the payment made by the insurer after copay and deductibles.
Instead of researching why insurance companies are contracting with fewer and fewer providers, lawmakers are being called upon to promote legislation including: bans on out-of-network payments, requirements for cost estimates delivered to patients prior to procedures, and detailing dispute resolution measures.
Out-of-network payment is a high-level issue of concern for ASA, state component societies, and a growing number of stakeholders including medical specialty organizations, insurers, patients and consumer groups, large group practices, and others. To address the growing impact this subject has on state component societies advocacy and public relations efforts, the Executive Committee (EC) approved an Ad Hoc Committee on Out-of-Network Payment (AHCONP). Chaired by Sherif Zaafran, M.D., AHCONP is developing materials for state component societies, messaging for ASA, and serving as a resource for states engaged in out-of-network payment initiatives. Additionally, AHCONP is leading efforts to ensure medical specialty organizations are working together on these issues.
In the event your state is considering out-of-network legislation, please contact ASA Director of State Affairs, Jason Hansen, at firstname.lastname@example.org.
• Watch the Brookings event: https://www.brookings.edu/events/protecting-patients-from-surprise-medical-bills/
• Read the Brookings policy paper: https://www.brookings.edu/wp-content/uploads/2016/10/sbb1.pdf